Laws that Conflict with the Ethics of Medicine: What Should Doctors Do?

By Dena S. Davis and Eric Kodish
Hastings Center Report 44, no. 6 (2014): 11-14.
DOI: 10.1002/hast.382

Here is an excerpt:

Medical ethics has always asked doctors to put their patients first, even at some risk to themselves. “Medicine is, at its center, a moral enterprise grounded in a covenant of trust,” writes Christine Cassell. “This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.”[19] Physicians are expected to care for patients with infectious diseases, even at risk of their own health. Physicians are expected to do some pro bono work, to take on some patients who are not financial assets, and so on. Physicians should be advocates for the health of all people, above and beyond even their own patients. The AAP is “dedicated to the health of all children.”[20] The imperative to act on this ethical norm clearly suggests that physicians should challenge these types of laws. On rare occasions, individual doctors may be ethically justified in disobeying or breaking the law.

The entire article is here.

Putting dignity to work

By Charles Foster
The Lancet
Originally published June 2, 2012

A profoundly brain-damaged teenage girl is brought to hospital. The nurses undress her and leave her, uncovered, on a trolley in front of some lascivious youths who are waiting in the Accident and Emergency Department. She seems to enjoy receiving their attention; they enjoy giving it. Is this wrong? Yes it is. But what language describes the wrongness? Certainly the four principles laid out by Tom Beauchamp and James Childress in their classic Principles of Biomedical Ethics (autonomy, beneficence, non-maleficence, and justice) can't really help, or can't help without straining uncomfortably. Autonomy isn't offended. Insofar as the girl is capable of exercising autonomous thought, she's all for it, and so are the boys. And there's no real harm here, as harm would conventionally be described. One might say that the maxim “Do good” has been violated, but what does “good” mean?

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In answering that question, and in saying what is meant by “good”, it is hard to avoid using words like dignity. And that, for many, is rather embarrassing. Dignity has a bad reputation among some philosophers. It tends to be thought of as feel-good philosophical window-dressing—the name you give to whatever principle gives you the answer you think is right; as a substitute for hard thinking; as impossibly amorphous or (because of its historical association with the notion of the Imago Dei), as incurably theological. Dignity-peddlers, it tends to be thought, are selling metaphysical snake oil.

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Beauchamp and Childress sometimes falter because their principles are second-order principles, derived ultimately from dignity. Sometimes, to get the right ethical answer, you've got to go to the source. Burrow down deep enough into any bioethical conundrum, and you'll eventually hit dignity.

The entire article is here.

Reviewing Autonomy

Implications of the Neurosciences and the Free Will Debate for the Principle of Respect for the Patient's Autonomy

Sabine Muller & Henrik Walter. Cambridge Quarterly of Healthcare Ethics. New York: Apr 2010. Vol. 19, Iss. 2; pg. 205, 13 pgs

Introduction

Beauchamp and Childress have performed a great service by strengthening the principle of respect for the patient's autonomy against the paternalism that dominated medicine until at least the 1970s. Nevertheless, we think that the concept of autonomy should be elaborated further. We suggest such an elaboration built on recent developments within the neurosciences and the free will debate. The reason for this suggestion is at least twofold: First, Beauchamp and Childress neglect some important elements of autonomy. Second, neuroscience itself needs a conceptual apparatus to deal with the neural basis of autonomy for diagnostic purposes. This desideratum is actually increasing because modern therapy options can considerably influence the neural basis of autonomy itself.

Beauchamp and Childress analyze autonomous actions in terms of normal choosers who act (1) intentionally, (2) with understanding, and (3) without controlling influences (coercion, persuasion, and manipulation) that determine their actions. ¹ In terms of the free will debate, the absence of external controlling influences, their third criterion, corresponds to the freedom of action: to do what one wants to do without being hindered to do so. Criteria one and two are related to volition: that a choice is intentional, that is, that it has a certain goal that is properly understood by the person choosing.

According to Beauchamp and Childress, the principle of autonomy implies that patients have the right to choose between different medical therapy options taking into account risks and benefits as well as their personal situation and individual values. To enable an autonomous decision the procedure of informed consent ² has been developed. This procedure has become the gold standard in almost every part of medicine. Importantly, Beauchamp and Childress demand respect for a patient's autonomy under the premise that the patient is able to act in a sufficiently autonomous manner. ³ The crucial question in a special situation is whether this is the case.

Let us consider the example of the recent controversial discussion of Body Integrity Identity disorder: ⁴ If a patient asks a physician to amputate one of his legs although it neither hurts nor is deformed, paralyzed, or ugly (in the patient's view), and if the patient understands the consequences of the amputation and is not controlled by external influences, then one could deduce from the principle of respect for the patient's autonomy that the physician should amputate the leg. Although some commentators regard this as self-evident, we think that the case is not yet made, as it is important which internal processes have led to the wish of the patient.

We propose to add a fourth criterion for autonomous actions, namely, freedom of internal coercive influences. In the case of the patient who desires an amputation, it would have to be investigated whether his decision is based on internal coercion. Clear examples for that would be an acute episode of schizophrenia or a brain tumor. More controversial are neurotic beliefs, obsession and compulsion, severe personality disorders, or neurological dysfunctions not accessible with conventional diagnostic tools.

Although Beauchamp and Childress have not elaborated the principle of autonomy with regard to internal coercions, they clearly argue that the obligations to respect autonomy do not apply to persons who show a substantial lack of autonomy because they are immature, incapacitated, ignorant, coerced, or exploited, for example, infants, irrationally suicidal individuals, severely demented subjects, or drug-dependent patients. ⁵ But these kinds of patients are treated in medical ethics as exceptions and therefore as marginal cases. They are not considered to be important for the formulation of the principles.

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